Death: Let's Talk About It

Death, despite its inevitability, is often not spoken about, let alone planned for. To get people talking about this subject, the sister-in-law of a young mother who died of a brain tumor has initiated a simple project that consists of five key questions regarding end-of-life preferences. She asked medical bloggers to spread the word about Engage With Grace via the Internet just prior to Thanksgiving, with the hope that as families gathered for turkey and pumpkin pie, they would also make the opportunity to talk about death. Maudlin, you say? Considerate would be a better word. Don’t we owe it to ourselves, and to those who might have the responsibility of making decisions for us as we near the end of our days, to make our wishes known?

It is not a complicated set of questions. They are: Given the choice, would you prefer to die at home or in a hospital? Can a loved one accurately say how you’d like to be treated in the case of a terminal illness? Have you appointed someone to advocate for you as the end nears? Have you written a living will, arranged a medical power of attorney or completed an advanced directive? The fifth question asks where you might fall on a scale that extends from ‘no treatment whatsoever’ to ‘make every possible effort, including unproven treatments.’

As I scanned responses to the request, I read one from a physician who believes that stating one’s desires might be a wasted effort because one’s wants would more than likely change, depending upon the circumstances surrounding one’s end of life. A nurse answered his comments by admitting that, yes, preferences could change over the course of a lifetime but the importance of the questions and answers being discussed at all far outweighs that possibility. Planting a seed for thought is a step in the right direction to getting us to consider these questions and to make decisions accordingly.

Physicians and nurses should be open to assisting patients in making these decisions, if their advice is sought. More to the point, perhaps this is a conversation that should be initiated by the physician or nurse during routine visits. Why wait for the patient to think of it on his own? Before we reach senior status, when we are feeling hale and hardy,such details are easily pushed aside as something we’ll need to handle much farther down the road. Along with ‘do you smoke, drink, exercise and wear your seatbelt,’ why not add, ‘have you made your wishes known regarding your medical treatment in a situation where you are unable to speak for yourself?’

Your thoughts on this subject would be appreciated.

The Sky is Falling---or is It?

I’m beginning to feel a bit like Chicken Little—and, on top of that, more than a little confused. I had breakfast with my oncology nurse friend, Rita, a few days ago and told her of my impending surgery and my concern about C. diff. She didn’t laugh at me outright, but she certainly had to rein in a chuckle.

Rita thinks I’m over-reacting. Big time. She pointed out that C. diff is everywhere (yes, that’s why I’m concerned) and it’s obvious that the C. diff bug is old hat to her. She works with patients who have immune systems that are compromised and there have been no C. diff infections in her unit’s population. Because I have a healthy immune system, she believes that chances are miniscule that I’ll fall victim to the little gut buster that is C. diff.

It’s good to know the odds are in my favor but I seem to have a penchant for ending up on the unfavorable end of the odds scale. It has happened to me several times. If the chances of something bad happening are one in a hundred and I am that one—well, there’s no consolation in having started out with favorable odds.

So, tell me what you think. Am I running around squawking that the sky is falling when it’s not, or do I have a legitimate worry? I know I’m not supposed to believe everything I read, but I’ve been reading plenty about C. diff and the articles I’ve read are in agreement that C. diff poses more than a casual threat. Not every case study I’ve read has involved the elderly, infirm or immunologically compromised—so, that means I’m vulnerable, doesn’t it?

Do I need to pack those bleach-infused wipes, subject everyone who comes near me to the third degree about whether they’ve washed their hands properly and autoclave the clothing I bring home from the hospital, or not?

Help me sort this out, will you?

C. diff is Putting a Pall on My Hospital Holiday

I admit it. This renegade C. diff bug that is running amok in hospitals has me more than a little freaked out. No sooner had I posted to this blog about the uber-nasty germ than I learned I’d be going under the knife for the second time this year. I’m one of the few people around who actually enjoys being a patient in the hospital. During my first hospitalization of the year last January, I embraced the idea of a forced vacation and loved all the amenities of my spacious private room. I fell into the ‘ignorance is bliss’ category because I had never heard of C. diff.

Now, all of that has changed. In the past couple months it seems that every time I open a newspaper, a C. diff-related headline is staring me in the face. I read every article and, believe me, I have been properly sensitized—to the point that I am far more concerned about being ambushed by the little bugger than I am about the surgical procedure I’ll be having. I trust my doctor. I don’t trust C. diff one tiny bit.

The latest news to make my hair stand on end is that researchers determined that following routine cleaning at a hospital, 78 percent of surfaces remained contaminated. That does it! I’m going to the hospital armed—with wipes infused with bleach so I can clean everything around me. My tray table, bed rails, TV remote, call light—and I can’t wait to see my doctor’s face when I clean her stethoscope before I allow her to put it to my chest.

Now I’ve learned that even if I make it out of the hospital uninfected, my vigilance needs to continue once I’m back home. I’m to assume that anything I bring home from the hospital is contaminated. That means I won’t be bringing my cool fat water jug with the bendable straw or the cute pink basin as souvenirs. Any clothing that makes the trip to the hospital and back with me must be immediately laundered—and separately from the family wash. Regular detergent and hot water won’t eradicate the sneaky bug. To kill it dead, bleach is required, which I guess means I should take only white clothing to the hospital.

This is getting complicated but I definitely plan to take all of these precautions and more.

To those of you who are doing daily duty at the bedside, have you seen patients being proactive in the way I plan to be? Are you OK with that? Share your opinions, please.

A Super-Bug of Increasing Concern

Hand hygiene is in the news again, this time as part of the antidote for the much bigger news story, the nasty gut bug Clostridium difficile (C. diff). Largely hospital acquired, C. diff is virulent, difficult to treat and it can be deadly. The most toxic strain of the organism, which can produce up to 20 times the level of toxins than less benign strains, are drug resistant and respond to only the most powerful antibiotics, putting it second only to the super-bug MRSA in difficulty of treatment. The elderly and debilitated are most at risk from the effects of C. diff, ranging from severe diarrhea and colitis to blood poisoning and death.

The Centers for Disease Control and Prevention (CDC) estimates that 13 in every 1,000 hospital admissions become infected with C. diff. That doesn’t seem like many, does it? It didn’t seem so to me initially, but I suspect I am simply so provincial that I have trouble seeing the big picture beyond my relatively small community. Therefore, it wasn’t until I saw those numbers taken to the next level that the enormity of the danger became apparent to me. The cold, hard statistics are that 13 in every 1,000 patients equals 7,000 infections and 300 deaths on any single day, nationwide.

Even more shocking are the numbers that result when C. diff infections extend a patient’s hospital stay and increase the cost of care. If the number of infections reported in a recent survey were extrapolated to all hospitals in the U.S. on a single day, those patients would tally more than $32 million in costs, on average, and an astounding 40,000 extra days of hospitalization.

Inadequately cleaned surfaces are the major culprits in the spread of C. diff. The pathogen’s hard-to-kill spores are transmitted in feces. Infection occurs when people ingest the spores, most often by touching surfaces and then touching their mouths. Contaminated food can also be a source of contact.

Prevention of this potentially fatal infection involves teamwork. Hospital employees at all levels need to be more diligent than ever regarding environmental hygiene. Sanitizing hands and equipment must be priorities. The usual hospital disinfectants are not effective in killing C. diff. A strong bleach solution is required to eradicate C. diff spores and should be used to clean all surfaces and equipment. It would be good to follow the lead of one chief of infection control at a large metropolitan hospital, who reports that rooms in his facility are inspected with as much rigor, if not more, than is the kitchen.

Patients and families need to do their part, too. They need to avoid asking for antibiotics indiscriminately (and doctors need not to cave in to patients’ demands), so that C. diff does not build up further immunity to antibiotic treatment. It should be emphasized that hand hygiene is as important for the lay public as for caregivers. Patients and families need to know that it is acceptable to question any and all caregivers as to whether equipment and hands have been properly sanitized.

Imparting this information to patients, family members and fellow employees presents a teaching opportunity—or necessity—for nurses. I know, we have enough to do without dealing with another opportunity, but we have to engage our patients anyway, so conversation can employ teaching and vice versa.

Has C. diff been a problem in your workplace? How is it dealt with?